World Journal of Surgery

, Volume 30, Issue 5, pp 833–840 | Cite as

Selective Modified Radical Neck Dissection for Papillary Thyroid Cancer—Is Level I, II and V Dissection Always Necessary?

  • N. R. Caron
  • Y. Y. Tan
  • J. B. Ogilvie
  • F. Triponez
  • E. S. Reiff
  • E. Kebebew
  • Q. Y. Duh
  • O. H. Clark
Article

Abstract

Background

There is ongoing controversy as to the indications for and extent of lateral cervical lymphadenectomy for patients with papillary thyroid cancer (PTC). While most now agree that prophylactic lymph node dissections (LND) play no role, at the University of California, San Francisco (UCSF) we limit LND selectively on a level by level basis, and resect only the levels thought to harbor disease or to be at increased risk of metastases. This initial ‚selective LND’ usually includes levels III and IV (due to the well-documented increased likelihood of metastases to these levels) and levels I, II, and V are included when there is clinical or radiological evidence of disease or increased risk of it.

Methods

A retrospective review of the clinical charts and hospital records of 106 consecutive patients who had metastatic PTC and who underwent at least one lateral cervical LND at UCSF between January 1995 and December 2003 was carried out. Data were collected to assess which patients had levels I, II, and/or V included in their initial ipsilateral and/or contralateral LND and to determine the recurrence rates at these levels if they had previously been excised compared with if they had not. Chi-squared and Fisher exact tests were utilized for statistical comparison, where appropriate.

Results

A total of 140 initial lateral LND were performed: 104 ipsilateral and 36 contralateral. In these initial LND, 3.9%, 72.5%, and 18.6% of patients had levels I, II, and V resected on the ipsilateral side, and 2.9%, 60.0%, and 37.1% of patients had levels I, II, and V resected on the contralateral side. Recurrence at levels I and V was uncommon in all patient populations. Recurrence at level II was 19% ipsilaterally and 10% contralaterally when the level was previously resected and 21% ipsilaterally and 14% contralaterally when the level was not previously resected. There was no statistically significant difference in recurrence at level II when the level had previously been resected compared with when it had not.

Conclusions

If utilized in the appropriate patient population, a selective approach to lateral cervical LND for PTC can be a successful alternative to the routine modified radical LND. Levels I and V do not require resection unless there is clinical or radiological evidence of disease. Guidelines for which patients may be considered for this less aggressive approach to level II nodal metastases are suggested.

Differentiated thyroid cancer is second only to ovarian cancer as the most common endocrine malignancy.1,2 Papillary thyroid cancer (PTC) accounts for about 80% of all differentiated thyroid cancers1 and is the most likely of all thyroid malignancies to metastasize to the cervical lymph nodes.3 Lymphatic metastases develop in 30%–90% of patients with PTC,4, 5, 6 depending not only on the actual pathological stage of the disease, but also on which diagnostic modalities are employed to assess for potential metastases. These regional metastases are associated with an increased locoregional recurrence rate7 and a 30% recurrence rate in the lateral lymph nodes.8 Although most believe these regional metastases do not adversely influence survival,1,5 some have found that cervical metastases can be associated with an increase in overall mortality rate in selected patient populations.5,9,10 Patients with regional PTC metastases should have a therapeutic lymph node dissection (LND) and most agree that prophylactic lateral LND is no longer indicated.3,11 There is ongoing controversy as to the indications for and the extent of lymphadenectomy for patients with PTC. A major question remains as to the therapeutic benefits of a more or less extensive lymphadenectomy.

Therapeutic LND for patients with PTC range from a “berry picking” or selective nodal excision, in which only the specific lymph node(s) that are grossly diseased are excised, to a formal modified radical LND (MRND) in which all lymphatic tissue within the cervical lymph node levels I, II, III, IV, and V are removed.5 Rarely, elements such as the internal jugular vein, sternocleidomastoid muscle, and/or the spinal accessory nerve are excised en bloc if there is evidence of invasion at the time of the procedure, but the traditional radical LND in which all 3 structures are routinely excised with the lymph tissue is no longer advocated for PTC. An intermediate approach between the berry picking procedure and the MRND is the “selective LND“ in which a formal compartment-oriented approach is utilized, but not all levels from I to V are routinely excised. For example, most centers will not perform a level I dissection in the absence of clinically or radiologically evident disease, as it is quite rare for PTC to metastasize to this level.6 Overall, there is no conclusive evidence that one approach is superior to the others, although most believe that the berry picking procedure should only be used for lymphatic metastases that have recurred in the face of a previous anatomical dissection.4,12

For patients initially presenting with lymphatic PTC metastases at the University of California, San Francisco (UCSF), we perform a selective LND to resect all levels with metastatic disease evident preoperatively and/or intraoperatively. As the most common lateral lymph node regions found to harbor metastases are levels III and IV5,8,13 (the first lateral lymph node basins draining the thyroid gland), these levels are usually resected using the traditional MRND surgical landmarks. Levels I and V are only resected if there is synchronous or metachronous evidence of disease. Level II is resected if there is evidence of disease or if there is extensive nodal involvement at level III, even if level II is clinically and ultrasonographically clear of tumor. If a patient who has not had levels I, II and/or V resected at their previous LND(s) experiences recurrence at one or more of these levels, they are treated with an anatomic clearing of this region. If a patient experiences recurrence in a cervical level previously resected, a berry picking procedure is used to remove the lymph node(s) involved.

The purpose of this study was to review our surgical approach to PTC lymphatic metastases. The initial LNDs performed for patients with PTC at UCSF were reviewed to identify how many required level I, II, and/or V to be resected, whether such dissections were positive on pathologic evaluation, and how the rate of recurrence at levels I, II, and V compared when these levels had not been previously dissected (de novo recurrence) versus when they had been previously resected.

MATERIALS AND METHODS

The clinical charts and electronic hospital records of 106 consecutive patients who had had metastatic PTC and who had undergone at least 1 lateral LND at UCSF between January 1995 and December 2003 were reviewed. The follow-up period extended from the time of their first thyroid operation (or completion thyroidectomy) until 10 December 2004. Lymph node recurrence was documented if lymphatic metastases developed in the lateral lymph nodes on the side previously resected—regardless of what levels of lymph nodes had experienced recurrence or had been resected previously. The first ipsilateral and contralateral LND were recorded as the baseline and the presence and time to the first documented ipsilateral and contralateral recurrences were recorded for evaluation. When multiple recurrences were noted, only initial LNDs and the LNDs for the first regional recurrences on each side were evaluated. Further treatments were usually limited to berry picking removal of nodes or non-operative treatment options such as radioactive iodine (RAI) or external beam radiation.

Each LND was performed by the attending endocrine surgeon with an endocrine surgery fellow or surgical resident. The initial LND for clinically or radiologically evident lymphadenopathy on either side was an anatomically based selective LND as described above—directed by which cervical levels had evidence of disease. Although some patients had their initial LND at the time of their thyroidectomy for primary disease, others had lymphatic metastases identified during patient follow-up that included clinical evaluation, radiology investigations (most commonly ultrasound), serum thyroglobulin (Tg) levels and RAI scans. Clinical or radiological suspicions of recurrence were usually confirmed with fine needle aspiration biopsy prior to operative intervention, especially if the suspected recurrence occurred at a level previously dissected.

The operative approach at UCSF to this lymphatic recurrence was as described previously. The levels of dissection were documented based on the anatomical description in the operative dictation. No prophylactic lateral lymphadenectomies were performed. LND were recorded as ipsilateral, contralateral or bilateral to the primary tumor, as described in the operative note and pathology reports. When the PTC was bilateral, the LND on the side of the largest primary lesion was considered “ipsilateral.” If a pathology report confirmed lymphatic metastases, but did not clearly document which lymphatic levels were positive, all lymph node regions excised were considered to be positive.

Data including patient demographics, tumor and lymph node pathology, types of surgical and adjuvant treatments, timing and rate of recurrence, and mortality were collected. This descriptive analysis documents the overall number of patients who had LND for PTC (ipsilateral and contralateral), the number of patients who had levels I, II, and/or V excised at their initial LND, how many of these pathology specimens confirmed metastatic disease (overall and within levels I, II, and V), and which patients went on to develop recurrence (overall and within levels I, II, and V). Chi-squared and Fisher exact tests were utilized for statistical analysis, where appropriate.

RESULTS

A total of 140 initial lateral LND were performed on the 106 patients (74 women and 32 men) with metastatic PTC between January 1995 and December 2003. The average patient age at their initial assessment was 38.7 years. Of these initial LND, 104 were ipsilateral to the primary tumor and 36 were contralateral to the primary tumor. Only 34 patients actually had bilateral LNDs because 2 patients had disease isolated to the contralateral side, with no evidence of ipsilateral lymphatic metastases. In both of these cases, the tumors were multifocal with lesions greater than 1 cm on each side. Overall, 32 out of 106 (30%) patients were documented to have multifocal PTC. Specific levels of LNDs were not obtainable in 2 patients with ipsilateral LNDs and in 1 patient with a contralateral LND. These patients were excluded from further analysis.

Table 1 documents the number of LNDs, the proportion of patients with positive or negative lymph node pathology, and the overall recurrence rates, independent of individual nodal levels. The LNDs evaluated include the 102 initial ipsilateral and 35 initial contralateral LNDs along with 29 ipsilateral and 9 contralateral LNDs for first-time recurrent disease on either side (175 LND in total).
Table 1

Overview of lymph node dissections (LND) for papillary thyroid cancer (PTC)

Ipsilateral LND

 

  Number of patients with 1 or more LND

102

  Number of patients with at least 1 (+) node on initial LND

95/102 (93%)

  Number of patients with all (−) nodes on initial LND

7/102 (6.9%)

  Number of patients who had 2 or more ipsilateral LND (recurrent disease)

29/102 (28%) (1 patient had previously (−) pathology on initial LND specimen)

Contralateral LND

 

  Number of patients with 1 or more LND

35

  Number of patients with at least 1(+) node on initial LND

26/35 (74%)

  Number of patients with all (−) nodes on initial LND

9/35 (26%)

  Number of patients who had 2 or more contralateral LND (recurrent disease)

9/35 (26%) (1 patient had previously (−) pathology on initial LND specimen)

Bilateral LND

 

  Number of patients

34

  Number of patients with bilateral recurrence

4

(+) = disease evident on pathology, (−) = no disease evident on pathology.

Average duration of patient follow-up was 4.5 years. All patients at UCSF with PTC and lymph node metastases are recommended to have post-thyroidectomy RAI scanning and ablation and this is documented in UCSF records in all but 8 patients. There were 13 patients with documented distant metastases, most commonly to the lung (10 out of 13). Of interest, multiple lymph node recurrences per side (documented by 3 or more LND on one side) developed ipsilaterally in 5 patients and contralaterally in 2 patients. Due to the large referral area for UCSF endocrine surgery, follow-up RAI investigations and treatment, thyroid hormone suppression, and serum Tg monitoring were often performed at the initial referral center so data for these details were not complete in the UCSF database. External beam radiation was only administered to the 7 patients who did not have further surgical or RAI treatment options for their persistent or recurrent disease. There was one death recorded in this 10-year period.

Table 2 displays the ipsilateral LND results broken down by the cervical lymph node levels in question. PTC rarely recurred at levels I and V regardless of whether these lymphatic regions had previously been found to be positive for metastatic disease, negative for metastatic disease or simply not dissected. There were three recurrences in total (3%) at levels I and V, which developed within 1 year of the initial ipsilateral LND (8.8 to 11.2 months postoperatively). None of the patients had metastatic disease to level I in the absence of documented level II disease.
Table 2

Ipsilateral lymph node dissections

 

Level I

Level II

Level V

Included with initial LND

4/102

74/102

19/102

(+) for metastases

4/4 (100%)

59/74 (80%)

12/19 (63%)

Recurrence at this level if previously resected

0/4 (0%)

14/74 (19%)

1/19 (5%)

Recurrence at this level if previously resected and this level was:

   

  Positive for metastatic disease at 1st LND

0/4

11/14

1/1

  Negative for metastatic disease at 1st LND

0/4

3/14

0/1

Not included with initial LND

98/102

28/102

83/102

Recurrence at this level if not previously resected

1/98 (1%)

6/28 (21%)

1/83 (1%)

The ipsilateral level II recurrence rate was 19% (14 out of 74) when level II had previously been resected. Most of these recurrences (11 out of 14, 79%) occurred when this level was initially positive for metastatic disease (mean time to recurrence 8.9 months) and only 3 out of 14 (21%) recurrences developed when level II was initially negative for metastatic disease (mean time to recurrence 17.4 months). When the initial ipsilateral LND did not include level II, 6 out of 28 (21%) patients developed de novo level II recurrence while the majority (22 out of 28, 79%) did not recur at level II. This de novo level II recurrence developed within a median of 5.5 months from the initial LND. There was no statistically significant difference between level II recurrences when this level had previously been resected compared with when it was not (OR: 1.17; CI: 0.40–3.42; P = 0.78).

Of the 28 patients who did not have level II excised at the initial ipsilateral LND, 22 (79%) had metastatic disease at level III, 4 (14%) had level III specimens that were negative for metastatic disease, and 2 (7%) did not have level III lymph nodes excised. All 6 patients in this group who developed de novo ipsilateral recurrence at level II had documented metastatic disease to level III at the initial LND.

Table 3 displays the contralateral LND results broken down by the cervical lymph node levels in question. Similar to the ipsilateral side, level I was rarely included in the initial LND for PTC (1 out of 35, 3%) and even when it was not included, only 2 out of 35 (6%) patients developed de novo level I recurrence at follow-up (at 4.0 and 37.5 months). None of the patients had metastatic disease to level I in the absence of documented level II disease. A greater percentage of patients had level V metastases at the initial contralateral LND (8 out of 35, 23%) than on the ipsilateral side (12 out of 102, 12%). This was not a statistically significant difference (OR: 2.2; CI: 0.8–6.0) and none of the patients developed contralateral level V recurrence, whether this level was initially positive for metastatic disease, initially negative for metastatic disease or not even included in the initial contralateral LND.
Table 3

Contralateral lymph node dissections

 

Level I

Level II

Level V

Included with initial LND

1/35

21/35

13/35

(+) for metastatic disease

0/1 (0%)

15/21 (71%)

8/13 (62%)

Recurrence at this level if previously resected

0/1 (0%)

2/21 (9%)

0/13 (0%)

Recurrence at this level if previously resected and this level was:

   

  Positive for metastatic disease at 1st LND

0/0

2/2

0/0

  Negative for metastatic disease at 1st LND

0/0

0/2

0/0

Not included with initial LND

34/35

14/35

22/35

Recurrence at this level if not previously resected

2/34 (6%)

2/14 (14%)

0/22 (0%)

The contralateral level II recurrence rate was 2 out of 21 (9.5%) when level II had previously been resected. Both of these recurrences occurred when this level was initially positive for metastatic disease with a mean time to recurrence of 10.2 months. None of the patients developed level II recurrence when level II was initially negative for disease. When the initial contralateral LND did not include level II, 2 out of 14 (14%) patients developed de novo level II recurrence (in a mean of 29 months), while the majority (12 out of 14, 86%) did not recur at level II. As with the ipsilateral side, there was no statistically significant difference between level II recurrence rates when this level was not previously resected, compared with when it was previously resected (OR: 1.58; CI: 0.20–12.79; P = 0.66)

Of the 14 patients who did not have level II excised at the initial contralateral LND, 8 (57%) had metastatic disease at level III, 3 (21%) had level III nodes that were negative for metastatic disease, and 3 (21%) did not have level III lymph nodes excised. The contralateral level III was positive for metastatic disease in 1 patient who experienced recurrence at level II (at 37.6 months) and only level IV was excised in the other patient who developed level II recurrence (at 20.4 months). None of the patients with histologically negative level III lymph nodes developed disease recurrence—either at level II nor elsewhere.

DISCUSSION

The selective compartment-oriented LNDs performed at UCSF apply the same systematic anatomic approach as the MRND, but do so on a level-by-level basis depending on the presence of disease. Each level harboring metastases is cleared of all lymphatic tissue. A berry picking procedure is not advocated for this initial surgical treatment of PTC lymphatic metastases.4,12 While most agree that there is no role for prophylactic LND in patients with PTC,3,11 at UCSF we also limit prophylactic cervical dissections at levels that have no clinical or radiological evidence of disease. This approach resulted in 96% of level I, 31% of level II, and 77% of level V lymph nodes left in situ after the initial LNDs. As levels III and IV are most often involved with metastatic PTC5,8,13 (and may even house the sentinel node),14,15 these levels were almost always included in the initial lateral LND for patients with PTC.

The converse of these statistics dictates that 4% of level I, 69% of level II, and 23% of level V lymph nodes were excised at the initial LNDs as disease was evident clinically or radiologically (or, in the case of level II nodes, there was bulky disease evident at level III). The percentages of our patients who had these lymph node levels resected closely approximate (and are usually greater than) the actual recorded percentages of metastatic disease seen at these levels in past studies.5,6,13 This suggests that careful preoperative and intraoperative assessment of these lymph nodes can accurately determine which lymphatic levels should be excised.

Even with this selective approach, most patients at UCSF with PTC lymphatic metastases had level II resected (73% of ipsilateral and 60% of contralateral LNDs included level II). This selective approach resulted in most patients having pathologically confirmed metastatic disease in these level II specimens (80% ipsilateral level II specimens and 71% contralateral level II specimens were positive for metastatic disease). These percentages for yield of lymphatic metastases are much higher than those previous studies have shown when level II was routinely excised. In these studies, level II was pathologically positive for metastases in only 22%–56% of patients.5,6,13 In other words, these routinely resected level II specimens in previous investigations were negative for metastatic disease 44%–78% of the time. From this pathology point of view, there is room for a selective approach to lymphatic disease.

There is a select group of patients at UCSF who have never required a level II LND at any point during their treatment, regardless of whether one or more LND had been performed for lymphatic disease elsewhere. This includes 22% of patients with at least one ipsilateral LND and 34% of patients who have had at least one contralateral LND, and at the time of last follow-up, they had no evidence of recurrent disease.

A total of 42 out of 137 patients did not initially have level II resected (28 out of 102 ipsilateral LND and 14 out of 35 contralateral LND). While 8 out of 42 (18%) of these patients eventually recurred at level II, none recurred if level III was resected and found to be pathologically negative. This supports our approach of including clinically negative level II lymph nodes in a selective LND if there is clinically bulky disease at level III. This known progressive spread of lymphatic disease was also evident with level I nodes; none were found to be positive for metastatic disease in the absence of level II disease.

As most LND were performed for ipsilateral disease (131 out of 175, 75% of LND) a closer look at this ipsilateral level II was warranted. Of the 28 patients who did not have a level II dissection at the primary LND, 6 (21%) had level II recurrence. Of the 74 patients who did have level II dissected at the primary LND, 14 (19%) had level II recurrence. When considering these similar recurrence rates, it must be remembered that the two groups were clinically selected and were not randomized. Patients who had clinical disease at level II at the time of initial LND would have had this level included and such patients would be expected to have a higher level II recurrence rate. But in the absence of a prospective, randomized study, many factors in addition to surgical extent (disease factors or preoperative evaluations, for example) could have influenced these recurrence rates.

The patients who did not have level II included in the initial ipsilateral LND and subsequently experienced recurrence at level II did so within a relatively rapid time frame (mean time to recurrence was 5.5 months). This can be considered persistent disease. All had an initial LND limited to levels III and IV and both levels were positive for metastases in all 6 patients. This early recurrence/persistent disease may be due to lymphatic metastases missed on initial preoperative investigations, bulky level III disease that was not recognized at the first LND (which would have led to level II dissection) or simply aggressive disease that would have recurred regardless of initial LND approach.

The increasing use of cervical ultrasonography contributed to the apparently higher recurrence rate than some prior studies. Half of the level II recurrences in our patients who did not have initial level II dissection were not palpable and were identified by cervical ultrasonography during postoperative follow-up. In 3 out of 6 patients, the subsequent level II LND only identified single nodal involvement and 5 out of 6 patients had 3 or less “recurrent” metastatic nodes. It is controversial as to how aggressively to treat the “ultrasound-positive but palpation-negative” recurrences. Some of these cervical PTC metastases do not grow, as studies have reported that at least 75% of patients with PTC have occult lymph node metastases, but only about 20% become clinically evident.16,17 As ultrasound is more sensitive than palpation in identifying lymphadenopathy and not all metastatic lymph nodes grow to become clinically significant, the increasing use of postoperative cervical ultrasonography tends to overestimate the risk of clinical local recurrence. The current problem is that we still cannot predict which nodal metastases will behave in an aggressive manner. It seems appropriate that if postoperative ultrasounds are routine and documented lymphadenopathy will be considered “recurrences” and excised, then ultrasounds should be performed preoperatively so the initial selective approach can include this otherwise occult disease.

Even extensive preoperative imaging, however, cannot compare to the sensitivity of subsequent post-thyroidectomy evaluations that include serum TSH-stimulated RAI scans and serum Tg indications for additional tests such as MRI, CT, and PET scans. Not only are these post-thyroidectomy tests more sensitive, but our protocol for RAI scans requires endogenous TSH levels greater than 30 μ/l, which may stimulate occult lymphatic metastases to enlarge quickly and become clinically evident. Lymphatic metastases are simply more likely to be detected with these post-thyroidectomy investigations and this should be considered when the initial LND is performed at the time of thyroidectomy for the primary tumor (as opposed to the initial LND performed for metachronous disease when all these investigation options are available prior to the LND). Although the clinical significance of disease detected with these sensitive tests is unknown, the future use of RAI (for screening and treatment) and the use of serum Tg as a tumor marker depend in part on the absence of this gross disease.

Occasionally, patients who recur so quickly may simply have aggressive disease, such as the patient with a 3.5 cm, cribriform, poorly differentiated tumor that invaded the RLN and recurred within 5 months, not only at level II but also levels III and IV (invaded the lower cervical portion of the jugular vein and carotid artery), the superior mediastinal nodes (level VII), and the central neck (level VI nodes and esophageal invasion). This patient’s level II recurrence was unlikely to have been the outcome of the selective approach!

In other patients, however, an initial level II dissection may have prevented recurrence. One patient with ipsilateral level II recurrence had 8 out of 8 level III nodes positive for metastatic disease, while another had bilateral nodal metastases on presentation. Both had aggressive disease and would be expected to have a higher recurrence rate. These disease factors should be added to “bulky disease at contiguous level III” as factors to consider when evaluating the inclusion/exclusion of level II in a selective LND.

Evaluating the 6 patients who experienced recurrence early at level II showed us that some patients may not be good candidates for the selective LND approach at this level. While our pre-study criteria still identified candidates who demonstrated an 80% success rate, we have expanded this list of factors to be considered. Level II should be included at the initial LND when the patient has:
  1. 1.

    Clinically or radiologically positive level II lymph nodes

     
  2. 2.

    Signs of aggressive local disease (tumor subtype, local invasion)

     
  3. 3.

    Extensive contiguous level III disease (bulky, numerous or majority of level III nodes positive for metastases) or bilateral lymph node metastases

     

If the patients are to be followed by cervical ultrasonography postoperatively (which is becoming routine), they should have cervical ultrasonography preoperatively and adjust the LND approach as necessary.

If possible, these recurrences are resected. If the “recurrence” is isolated to a level not previously resected (levels I, II, and/or V), the surgical field is relatively free of scar tissue, which facilitates the complete clearance of lymphatic tissue from this (these) level(s). A McFee extension of the standard transverse Kocher cervical incision permits access to levels IV, III, and lower level II. If level V is required, the incision is extended posteriorly in a fashion that provides safe access to the nodal region. For an isolated level II recurrence, a 3-cm counter incision is usually made in a skin crease directly over the nodal region and parallel to the Kocher incision. If the recurrence is at (a) level(s) previously resected, a berry picking resection of the recurrent node(s) is used to minimize the amount of dissection required.

The limitations of our clinical investigation are related to the retrospective design. Although data were entered prospectively and a careful retrospective review of operative reports allowed most levels of each LND to be assessed, pathology reports often did not specify the number of benign and malignant nodes identified at each level. By assuming all levels had metastatic disease if not specified otherwise, the number of lymph node levels involved with lymphatic metastases was overestimated. This may have led to an increased number of patients initially documented with disease at level(s) I, II, and/or V, and/or recurrence at these levels. Ideally, a prospective investigation could be done where the operating surgeon would mark each level resected and then send them separately to pathology.

Conclusions

Our investigation documents that careful preoperative and intraoperative assessment can usually accurately determine which levels should be included in a selective LND. For the initial LND:
  1. 1.

    Any level with clinical or radiological evidence of metastatic disease should be completely cleared

     
  2. 2.

    Levels III and IV should always be excised even if disease is only evident at one of these levels, as these are the levels most commonly involved with PTC

     
  3. 3.

    Clinically negative level II lymph nodes should be excised if there are signs of aggressive local disease. extensive contiguous level III disease or bilateral lymph node metastases

     

If cervical ultrasound is becoming a routine postoperative investigation, it should be utilized preoperatively and the LND approach adjusted accordingly. A formal MRND including levels I, II, III, IV, and V is not necessary in all patients with PTC nodal metastases, but extreme care must be used when selecting the levels to be excised. Recurrent disease is excised with a selective anatomically oriented LND of the level(s) involved if the identified level(s) has (have) never been resected. All other recurrences are usually treated with selective/berry picking nodal resections.

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Copyright information

© Société Internationale de Chirurgie 2006

Authors and Affiliations

  • N. R. Caron
    • 1
  • Y. Y. Tan
    • 1
  • J. B. Ogilvie
    • 1
  • F. Triponez
    • 1
  • E. S. Reiff
    • 1
  • E. Kebebew
    • 1
  • Q. Y. Duh
    • 1
  • O. H. Clark
    • 1
  1. 1.Mount Zion Medical CenterUniversity of California, San FranciscoSan FranciscoUSA

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